Pain Psychology and the Biopsychosocial Model of Pain Treatment: Ethical Imperatives and Social Responsibility

Worldwide, the need for more effective treatment for pain has steadily gained recognition as the cornerstone of patient-centered care. Nationally, the Institute of Medicine’s (now Academy) report on Relieving Pain in America [1] and the National Pain Strategy [2] both specify a need to treat pain comprehensively, and to better educate clinicians across disciplines as to the importance of multidisciplinary pain care. Despite the psyche’s integral role in the experience of pain, few individuals or professionals are aware that pain is defined as an aversive “sensory and emotional experience,” [3] and even fewer understand how to address the emotional aspects of the pain experience. We underscore the ethical imperative to orient students, the public, medical care providers, and mental health professionals to the integral role of psychological factors in the experience of pain. In doing so, we hope to have the opportunity to steer the health of the population toward more effective treatment for pain.

Anecdotally, pain specialists and many primary care providers have long experienced difficulty referring individuals with chronic pain to psychologists skilled in pain treatment, or to therapists who address pain in the psychotherapeutic context. In part, the difficulty was attributed to a lack of health care insurance coverage for psychological services, or to strict limitations in coverage that rendered treatment insufficient and ineffective. Enactment of the Mental Health Parity Act, an aspect of the Patient Protection and Affordable Care Act [4], has led to improvements but barriers persist and continue to impede access to skilled providers. For instance, mental health provider panels approved by a carrier may include a severely limited number of psychologists and therapists skilled in treating pain, and provider availability may also be limited, thereby leaving patients with few good options. Such limited access to pain psychology may negatively impact patients with the greatest need in a disproportionate manner. Indeed, barriers exist to appropriate and sufficient psychological treatment for pain in those who require a higher level of care than is provided in weekly or bi-weekly treatment sessions. In short, many complex individuals require coordinated, interdisciplinary care with more intensive psychobehavioral treatment with pain experts, the efficacy of which has been well-established [5]. However, these services are often impossible due to poor insurance coverage for adequate and appropriate services. An ethical imperative exists for insurance to facilitate patient access to the psychological treatment of pain, and to the appropriate level of services for the individual patient. However, we also understand that private insurers are generally concerned about cost-containment and profitability, denying any fiduciary obligation to their enrollees [6,7]. Yet, the Mental Health Parity provision of the Affordable Care Act requires insurers to cover mental health services at parity with other medical services [8]. However, if more enrollees were to avail themselves of pain psychology treatment, there would certainly be no guarantee that insurers would not raise their premiums. Recently, the American Academy of Pain Medicine’s Pain Psychology Task Force spearheaded a national study and published the first report on pain psychology training, perceptions, resources, and needs in the United States [9]. Roughly 2,000 individuals across six key stakeholder groups were surveyed: individuals living with chronic pain, psychologists/therapists, pain physicians, primary care physicians/physician assistants, nurse practitioners, and directors of psychology graduate and post-graduate training programs. This study found that 72% of therapists and psychologist respondents reported having little or no formal pain training, and 55% endorsed low comfort levels in addressing and treating pain. Furthermore, 90% of therapist and psychologist respondents reported interest in no-cost pain education for psychologists[9]. Taken together, it is clear that part of the root cause of therapist and psychologist discomfort in treating pain aligns with the cause of physician discomfort with this patient population: insufficient training. The results suggest that everyday pain treatment often remains firmly in the biomedical realm, focusing upon nociception while failing to address the other half of the definition of pain that resides in the realm of psychology.

Pain education experts have advocated for improved and expanded pain education in medical schools [10,11], including emphasis upon the cognitive and affective dimensions of the pain experience[12,13]. However, the results of the national survey on pain psychology suggest that while medical providers may recognize the value of the biopsychosocial model of pain treatment, they appear to be lacking the resources to operationalize this model in their practices [9]. Research has singled out primary care as the principal gateway for over prescription of opioids [14], although this is not surprising given that the majority of chronic pain is treated in primary care [15]. However, primary care providers often have limited access to nondrug therapies due to a dearth of accessible pain psychology resources. We highlight the ethical imperative to better train psychologists and therapists to address and treat pain, and thereby provide primary care physicians, nurse practitioners, physician assistants, and other referring clinicians the resources they need to treat pain comprehensively according to the biopsychosocial model.

Pain education is needed at all levels of psychology training. Even at the undergraduate level, pain should be introduced and defined as a psychosensory experience. Advanced pain education is needed at the graduate and post-graduate levels. In the national study on pain psychology [9], the directors of psychology graduate training program respondents reported unanimous interest in learning more about a packaged, no-cost pain education program that could be integrated into their current trainings. Therapists and psychologists were similarly interested in learning more about no-cost trainings that would bolster their understanding and ability to treat pain. Taken together, the urgent need to provide behavioral treatments for pain, and the desire of psychologists to close educational gaps so that they may do so, creates an ethical imperative to systematically integrate pain education into psychology training.

Pain is public health problem that requires a more complex approach than do many other medical conditions. Furthermore, access to pain assessment and treatment should be considered a fundamental human right [9][16,17]. The devolution of the American pain care system from a “profession” to a mere “business” has been addressed [18], and until the United States adopts a single-payer system, pain care may remain a “commodity.” Additionally, pain remains the most common reason for medical visits to primary care practitioners [10], suggesting that we should be compelled to develop a system in which it is managed more effectively. Failure to provide adequate pain assessment and treatment represents an abrogation of the duty of the health care system and causes ongoing expenditures. The emotional dimensions of pain require our attention and we bear a social responsibility to ensure they are integrated into pain treatment at a population level. The social determinants of pain, injustice perceptions, social exclusion, stigmatization, pain catastrophizing, depressed mood, behaviors, motivation, anxiety, and fear all amplify or diminish pain. More than ever, we must expand pain education in the realm of psychology so that sufficient numbers of well-prepared psychologists and mental health professionals are equipped to empower their patients who suffer from pain. Only then can the World Health Organization’s definition of health as not merely the absence of disease, but also the achievement of each individual’s potential, be attained.

Funding

Funding is acknowledged from National Institutes of Health (NIH) National Center for Complementary and Integrative Health (NCCIH) 1R01AT008561-01A1 (BDD).